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  </style>
  <div class="wrapper">
    <div class="a4Wrapper">
      <table width="100%" class="MB0">
        <tbody>
          <tr>
            <td width="240">
              <h5 class="MB0 bold">CERTIFICATE OF:</h5>
              <p class="f12 MB4">(Please mark relevant check-box)</p>
            </td>
            <td>
              <table width='100%' class="MB0">
                <tbody>
                  <tr>
                    <td style="vertical-align: top;">
                      <input type="checkbox" id="checkbox1" class="MB0" style="width: 20px;height: 20px;" disabled="disabled" /> </td>
                    <td>
                      <label for="checkbox1">
                        <h6 class="MB0 f18 bold">TESTING AND COMPLIANCE</h6>
                        <p class="MB0 f12">Issued in accordance with s227 of the Electrical Safety Regulation 2013</p>
                      </label>
                    </td>
                    <td width="180">
                      <p class="MB0 f14 bold MB0">(Electrical installations)</p>
                    </td>
                  </tr>
                  <tr>
                    <td style="vertical-align: top;">
                      <input type="checkbox" id="checkbox2" class="MB0" style="width: 20px;height: 20px;"  disabled="disabled"/> </td>
                    <td>
                      <label for="checkbox2">
                        <h6 class="MB0 f18 bold">TESTING AND SAFETY</h6>
                        <p class="MB0 f12">Issued in accordance with s26 of the Electrical Safety Regulation 2013</p>
                      </label>
                    </td>
                    <td width="180">
                      <p class="MB0 f14 bold MB0">(Electrical equipment)</p>
                    </td>
                  </tr>
                </tbody>
              </table>
            </td>
          </tr>
        </tbody>
      </table>
      <table width="100%" class="MB0">
        <tbody>
          <tr>
            <td>
              <h5 class="MB6">* Work performed for:</h5>
            </td>
          </tr>
        </tbody>
      </table>
      <table width="100%" valign="top" class="MB0">
        <tbody>
          <tr>
            <td width='100' valign="top" class="text-right">
              <p class="a4FieldLabel">* Name</p>
            </td>
            <td valign="top">
              <p class="a4Field" id="work_performed_title"></p>
              <p class="a4PlaceHolder">Title</p>
            </td>
            <td valign="top">
              <p class="a4Field" id="work_performed_first_name"></p>
              <p class="a4PlaceHolder">Given name/s</p>
            </td>
            <td valign="top">
              <p class="a4Field" id="work_performed_last_name"></p>
              <p class="a4PlaceHolder">Surname</p>
            </td>
          </tr>
        </tbody>
      </table>
      <table width="100%" class="MB0">
        <tbody>
          <tr>
            <td width='100' valign="top" class="text-right">
              <p class="a4FieldLabel">* Address</p>
            </td>
            <td valign="top">
              <p class="a4Field" id="address_street"></p>
              <p class="a4PlaceHolder">Street</p>
            </td>
          </tr>
        </tbody>
      </table>
      <table width="100%" class="MB8">
        <tbody>
          <tr>
            <td width='100' valign="top">
              <p class="a4FieldLabel"></p>
            </td>
            <td valign="top">
              <p class="a4Field" id="address_suburb"></p>
              <p class="a4PlaceHolder">Suburb/town</p>
            </td>
            <td valign="top">
              <p class="a4Field" id="address_postcode"></p>
              <p class="a4PlaceHolder">Postcode</p>
            </td>
          </tr>
        </tbody>
      </table>
      <table width="100%" class="MB0">
        <tbody>
          <tr>
            <td>
              <h5 class="MB6">* Electrical installation / equipment tested
                <small>(please include site address for electrical installation work if different from above):</small></h5>
            </td>
          </tr>
        </tbody>
      </table>
      <p class="a4Textarea" id="electrical_installation_info"></p>
      <table width="100%" class="MB0">
        <tbody>
          <tr>
            <td width='100' valign="top">
              <p class="a4FieldLabel">* Date of test</p>
            </td>
            <td width='120' valign="top">
              <p class="a4Field" id="electrical_installation_date"></p>
            </td>
            <td width='280' valign="top">
              <p class="a4FieldLabel">* Electrical contractor licence number</p>
            </td>
            <td valign="top">
              <p class="a4Field" id="electrical_installation_licence"></p>
            </td>
          </tr>
        </tbody>
      </table>
      <table width="100%" class="MB0">
        <tbody>
          <tr>
            <td width="240" valign="top">
              <p class="a4FieldLabel">&nbsp;&nbsp; Name on contractor licence</p>
            </td>
            <td valign="top">
              <p class="a4Field" id="electrical_installation_name_licence"></p>
            </td>
          </tr>
        </tbody>
      </table>
      <table width="100%" class="MB0">
        <tbody>
          <tr>
            <td width="270" valign="top">
              <p class="a4FieldLabel">&nbsp;&nbsp; Electrical contractor phone number</p>
            </td>
            <td valign="top">
              <p class="a4Field" id="electrical_installation_phone_number"></p>
            </td>
          </tr>
        </tbody>
      </table>
      <table width="100%" class="MB0">
        <tbody>
          <tr>
            <td>
              <p class="f14" style="padding-left:10px;">For
                <strong>electrical installations</strong>, this certifies that the electrical installation, to the extent it is affected
                by the electrical work, has been tested to ensure that it is electrically safe and is in accordance with
                the requirements of the wiring rules and any other standard applying under the Electrical Safety Regulation
                2013 to the electrical installation.</p>
              <p class="f14" style="padding-left:10px;">For
                <strong>electrical equipment</strong>, this certifies that the electrical equipment, to the extent it is affected
                by the electrical work, is electrically safe.</p>
            </td>
          </tr>
        </tbody>
      </table>
      <table width="100%" class="MB0">
        <tbody>
          <tr>
            <td width='100' valign="top" class="text-right">
              <p class="a4FieldLabel">Name</p>
            </td>
            <td valign="top">
              <p class="a4Field" id="electrical_installation_name"></p>
              <p class="a4PlaceHolder">Person who performed, or person who is responsible for, the electrical work</p>
            </td>
          </tr>
        </tbody>
      </table>
      <table width="100%" class="MB0" style="height:73px">
        <tbody>
          <tr>
            <td width='100' height="73" valign="middle" class="text-right">
              <p class="a4FieldLabel">Signature</p>
            </td>
            <td valign="middle" style="height: 73px;vertical-align: middle;">
              <p class="a4Field" id="electrical_installation_signature" style="height: 73px;border: none;">
                <img id="electrical_installation_signature_img" src="" style="max-height:70px" />
              </p>
            </td>
            <td width="50" valign="middle">
              <p class="a4FieldLabel">Date</p>
            </td>
            <td width="150" valign="middle">
              <p class="a4Field" id="electrical_installation_signature_date"></p>
            </td>
          </tr>
        </tbody>
      </table>
      <table width="100%" class="MB0">
        <tbody>
          <tr>
            <td>
              <strong class="f14">* Indicates a mandatory field</strong>
            </td>
            <td class="text-right">
              <span class="f14">V4.12-2013</span>
            </td>
          </tr>
        </tbody>
      </table>
    </div>
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